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Janssen J, Staal F, Langendijk J, Both S, Brouwer C, Aluwini S. Pelvic lymph node motion during cone-beam computed tomography guided stereotactic radiotherapy. Clin Transl Radiat Oncol 2024; 47:100794. [PMID: 38798748 PMCID: PMC11127188 DOI: 10.1016/j.ctro.2024.100794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/29/2024] Open
Abstract
Background and purpose Stereotactic body radiotherapy (SBRT) is increasingly applied for pelvic lymph node recurrence. Thus far, knowledge on pelvic lymph node motion during CBCT-guided SBRT is lacking and the applied margins vary between institutions. This study evaluated pelvic lymph node motion during CBCT-guided SBRT and assessed the currently applied PTV margins of 3 and 5 mm. Material and methods In total, 45 pelvic lymph node metastases were included. One observer delineated 45 GTVs on planning CT, 224 GTVs on pre-fraction and 216 on post-fraction CBCT. The GTV centroid coordinates were derived from all images for inter- and intrafraction motion analysis. Additionally, we assessed the influence of treatment time and lesion location on lesion motion. The expected coverage of a 3-mm and 5-mm PTV margin was assessed using the inclusiveness index for GTVs on pre- and post-fraction CBCT. Results Lymph node interfraction motion was limited to 5 mm in 96-97 % of fractions for all translational directions and intrafraction lesion motion was limited to 3 mm in 97-100 % of fractions. Para-rectal lesions (11 %) were associated with significantly larger inter- and intrafraction motion compared to other pelvic locations and treatment duration showed no correlation with lesion motion. The mean (sd) lesion inclusiveness index was 99 % (5 %) for the 5-mm PTV margin and 96 % (9 %) for the 3-mm margin. Conclusion Pelvic lymph node motion during CBCT-guided stereotactic radiotherapy was within the widely applied PTV margin of 5 mm, providing an opportunity to reduce this margin for pelvic lymph node SBRT.
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Affiliation(s)
- J. Janssen
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - F.H.E. Staal
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - J.A. Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - S. Both
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - C.L. Brouwer
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - S. Aluwini
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Arp DT, Appelt AL, Brøndum RF, Mikalone R, Nielsen MS, Poulsen LØ. Individual lymph node position variation for rectal cancer patients treated with long course chemoradiotherapy. Phys Imaging Radiat Oncol 2024; 31:100599. [PMID: 39006757 PMCID: PMC11245935 DOI: 10.1016/j.phro.2024.100599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 07/16/2024] Open
Abstract
Background and purpose Delivery of high precision radiotherapy lymph node boosts requires detailed information on the interfraction positional variation of individual lymph nodes. In this study we characterized interfraction positional shifts of suspected malignant lymph nodes for rectal cancer patients receiving long course radiotherapy. Furthermore, we investigated parameters which could affect the magnitude of the position variation. Materials and Methods Fourteen patients from a prospective clinical imaging study with a total of 61 suspected malignant lymph nodes in the mesorectum, presacral, and lateral regions, were included. The primary gross tumor volume (GTVp) and all suspected malignant lymph nodes were delineated on six magnetic resonance imaging scans per patient. Positional variation was calculated as systematic and random errors, based on shifts of center-of-mass, and estimated relative to either bony structures or the GTVp using a hierarchical linear mixed model. Results Depending on location and direction, systematic and random variations (relative to bony structures) were within 0.6-2.8 mm and 0.6-2.9 mm, respectively. Systematic and random variations increased when evaluating position relative to GTVp (median increase of 0.6 mm and 0.5 mm, respectively). Correlations with scan time-point and relative bladder volume were found in some directions. Conclusions Using linear mixed modeling, we estimated systematic and random positional variation for suspected malignant lymph nodes in rectal cancer patients treated with long course radiotherapy. Statistically significant correlations of the magnitude of the lymph node shifts were found related to scan time-point and relative bladder volume.
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Affiliation(s)
- Dennis Tideman Arp
- Department of Medical Physics, Oncology, Aalborg University Hospital, Aalborg 9000, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg 9000, Denmark
| | - Ane L Appelt
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds LS2 9JT, UK
- Leeds Cancer Centre, St James's University Hospital, Leeds LS9 7TF, UK
| | - Rasmus Froberg Brøndum
- Center for Clinical Data Science, Aalborg University and Aalborg University Hospital, Aalborg 9000, Denmark
| | - Rasa Mikalone
- Department of Radiology, Aalborg University Hospital, Aalborg 9000, Denmark
| | - Martin Skovmos Nielsen
- Department of Medical Physics, Oncology, Aalborg University Hospital, Aalborg 9000, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg 9000, Denmark
| | - Laurids Østergaard Poulsen
- Department of Clinical Medicine, Aalborg University, Aalborg 9000, Denmark
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg 9000, Denmark
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Marinkovic M, Stojanovic-Rundic S, Stanojevic A, Tomasevic A, Jankovic R, Zoidakis J, Castellví-Bel S, Fijneman RJA, Cavic M, Radulovic M. Performance and Dimensionality of Pretreatment MRI Radiomics in Rectal Carcinoma Chemoradiotherapy Prediction. J Clin Med 2024; 13:421. [PMID: 38256556 PMCID: PMC10816962 DOI: 10.3390/jcm13020421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/22/2023] [Accepted: 12/25/2023] [Indexed: 01/24/2024] Open
Abstract
(1) Background: This study aimed to develop a machine learning model based on radiomics of pretreatment magnetic resonance imaging (MRI) 3D T2W contrast sequence scans combined with clinical parameters (CP) to predict neoadjuvant chemoradiotherapy (nCRT) response in patients with locally advanced rectal carcinoma (LARC). The study also assessed the impact of radiomics dimensionality on predictive performance. (2) Methods: Seventy-five patients were prospectively enrolled with clinicopathologically confirmed LARC and nCRT before surgery. Tumor properties were assessed by calculating 2141 radiomics features. Least absolute shrinkage selection operator (LASSO) and multivariate regression were used for feature selection. (3) Results: Two predictive models were constructed, one starting from 72 CP and 107 radiomics features, and the other from 72 CP and 1862 radiomics features. The models revealed moderately advantageous impact of increased dimensionality, with their predictive respective AUCs of 0.86 and 0.90 in the entire cohort and 0.84 within validation folds. Both models outperformed the CP-only model (AUC = 0.80) which served as the benchmark for predictive performance without radiomics. (4) Conclusions: Predictive models developed in this study combining pretreatment MRI radiomics and clinicopathological features may potentially provide a routine clinical predictor of chemoradiotherapy responders, enabling clinicians to personalize treatment strategies for rectal carcinoma.
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Affiliation(s)
- Mladen Marinkovic
- Clinic for Radiation Oncology and Diagnostics, Department of Radiation Oncology, Institute for Oncology and Radiology of Serbia, 11000 Belgrade, Serbia; (M.M.); (S.S.-R.); (A.T.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Suzana Stojanovic-Rundic
- Clinic for Radiation Oncology and Diagnostics, Department of Radiation Oncology, Institute for Oncology and Radiology of Serbia, 11000 Belgrade, Serbia; (M.M.); (S.S.-R.); (A.T.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Aleksandra Stanojevic
- Department of Experimental Oncology, Institute for Oncology and Radiology of Serbia, 11000 Belgrade, Serbia; (A.S.); (R.J.); (M.C.)
| | - Aleksandar Tomasevic
- Clinic for Radiation Oncology and Diagnostics, Department of Radiation Oncology, Institute for Oncology and Radiology of Serbia, 11000 Belgrade, Serbia; (M.M.); (S.S.-R.); (A.T.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Radmila Jankovic
- Department of Experimental Oncology, Institute for Oncology and Radiology of Serbia, 11000 Belgrade, Serbia; (A.S.); (R.J.); (M.C.)
| | - Jerome Zoidakis
- Department of Biotechnology, Biomedical Research Foundation, Academy of Athens, 11527 Athens, Greece;
- Department of Biology, National and Kapodistrian University of Athens, 15701 Athens, Greece
| | - Sergi Castellví-Bel
- Gastroenterology Deparment, Fundació de Recerca Clínic Barcelona-Institut d’Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Clínic Barcelona, University of Barcelona, 08036 Barcelona, Spain;
| | - Remond J. A. Fijneman
- Department of Pathology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | - Milena Cavic
- Department of Experimental Oncology, Institute for Oncology and Radiology of Serbia, 11000 Belgrade, Serbia; (A.S.); (R.J.); (M.C.)
| | - Marko Radulovic
- Department of Experimental Oncology, Institute for Oncology and Radiology of Serbia, 11000 Belgrade, Serbia; (A.S.); (R.J.); (M.C.)
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Fast MF, Cao M, Parikh P, Sonke JJ. Intrafraction Motion Management With MR-Guided Radiation Therapy. Semin Radiat Oncol 2024; 34:92-106. [PMID: 38105098 DOI: 10.1016/j.semradonc.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
High quality radiation therapy requires highly accurate and precise dose delivery. MR-guided radiotherapy (MRgRT), integrating an MRI scanner with a linear accelerator, offers excellent quality images in the treatment room without subjecting patient to ionizing radiation. MRgRT therefore provides a powerful tool for intrafraction motion management. This paper summarizes different sources of intrafraction motion for different disease sites and describes the MR imaging techniques available to visualize and quantify intrafraction motion. It provides an overview of MR guided motion management strategies and of the current technical capabilities of the commercially available MRgRT systems. It describes how these motion management capabilities are currently being used in clinical studies, protocols and provides a future outlook.
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Affiliation(s)
- Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Parag Parikh
- Department of Radiation Oncology, Henry Ford Health - Cancer, Detroit, MI
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Marinkovic M, Stojanovic-Rundic S, Stanojevic A, Ostojic M, Gavrilovic D, Jankovic R, Maksimovic N, Stroggilos R, Zoidakis J, Castellví-Bel S, Fijneman RJA, Cavic M. Exploring novel genetic and hematological predictors of response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer. Front Genet 2023; 14:1245594. [PMID: 37719698 PMCID: PMC10501402 DOI: 10.3389/fgene.2023.1245594] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/15/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction: The standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (nCRT). To select patients who would benefit the most from nCRT, there is a need for predictive biomarkers. The aim of this study was to evaluate the role of clinical, pathological, radiological, inflammation-related genetic, and hematological parameters in the prediction of post-nCRT response. Materials and methods: In silico analysis of published transcriptomics datasets was conducted to identify candidate genes, whose expression will be measured using quantitative Real Time PCR (qRT-PCR) in pretreatment formaline-fixed paraffin-embedded (FFPE) samples. In this study, 75 patients with LARC were prospectively included between June 2020-January 2022. Patients were assessed for tumor response in week 8 post-nCRT with pelvic MRI scan and rigid proctoscopy. For patients with a clinical complete response (cCR) and initially distant located tumor no immediate surgery was suggested ("watch and wait" approach). The response after surgery was assessed using histopathological tumor regression grading (TRG) categories from postoperative specimens by Mandard. Responders (R) were defined as patients with cCR without operative treatment, and those with TRG 1 and TRG 2 postoperative categories. Non-responders (NR) were patients classified as TRG 3-5. Results: Responders group comprised 35 patients (46.6%) and NR group 53.4% of patients. Analysis of published transcriptomics data identified genes that could predict response to treatment and their significance was assessed in our cohort by qRT-PCR. When comparison was made in the subgroup of patients who were operated (TRG1 vs. TRG4), the expression of IDO1 was significantly deregulated (p < 0.05). Among hematological parameters between R and NR a significant difference in the response was detected for neutrophil-to-monocyte ratio (NMR), initial basophil, eosinophil and monocyte counts (p < 0.01). According to MRI findings, non-responders more often presented with extramural vascular invasion (p < 0.05). Conclusion: Based on logistic regression model, factors associated with favorable response to nCRT were tumor morphology and hematological parameters which can be easily and routinely derived from initial laboratory results (NMR, eosinophil, basophil and monocyte counts) in a minimally invasive manner. Using various metrics, an aggregated score of the initial eosinophil, basophil, and monocyte counts demonstrated the best predictive performance.
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Affiliation(s)
- Mladen Marinkovic
- Department of Radiation Oncology, Clinic for Radiation Oncology and Diagnostics, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Suzana Stojanovic-Rundic
- Department of Radiation Oncology, Clinic for Radiation Oncology and Diagnostics, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksandra Stanojevic
- Department of Experimental Oncology, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Marija Ostojic
- Department of Experimental Oncology, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Dusica Gavrilovic
- Data Center, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Radmila Jankovic
- Department of Experimental Oncology, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | | | - Rafael Stroggilos
- Department of Biotechnology, Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Jerome Zoidakis
- Department of Biotechnology, Biomedical Research Foundation, Academy of Athens, Athens, Greece
- Department of Biology, National and Kapodistrian University of Athens, Athens, Greece
| | - Sergi Castellví-Bel
- Gastroenterology Department, Fundació Recerca Clínic Barcelona-Institut d’Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | | | - Milena Cavic
- Department of Experimental Oncology, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
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Smith D, Knight K, Sim J, Lim Joon D, Foroudi F, Khoo V. A planning-based feasibility study of MR-Linac treatment for anal cancer radiation therapy. Med Dosim 2023; 48:267-272. [PMID: 37507334 DOI: 10.1016/j.meddos.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
The hybrid magnetic resonance image (MRI) scanner and radiation therapy linear accelerator (MR-Linac) has the potential to enhance clinical outcomes for anal cancer (AC) patients with improved soft tissue visualization and daily plan adaption but has planning and delivery limitations due to the incorporation of MRI. We aimed to identify if Elekta Unity MR-Linac-based radiation therapy is feasible for anal cancer. Ten prospectively enrolled AC patients treated with radical chemoradiotherapy were replanned for MR-Linac treatment using departmental planning criteria. For comparison, and to reduce interobserver variability, volumetric modulated arc radiation therapy (VMAT) plans were also created for each patient by the same single senior radiation therapist. Plans were compared using departmental dosimetric plan criteria, as well as conformity and homogeneity indices, monitor units (MUs) and measured plan delivery (beam-on) time. Results were deemed clinically acceptable. Target and organ at risk (OAR) doses were comparable between MR-Linac plans and VMAT plans, although PTV45Gy D98% coverage was compromised in 3 of 10 MR-Linac plans due to caudocranial length exceeding the limits of the MR-Linac. MR-Linac plans had lower MUs, median of 689.1 vs 849.65 (p = 0.002), but took over twice as long to deliver, 529.5s vs 224s (p = <0.0001) as VMAT plans. MR-Linac planning and treatment of AC is feasible for a subset of patients. The current physical limitations of the Elekta Unity system mean patients with large caudocranial elective PTV45Gy target volumes may not be covered dosimetrically to the required clinical standard. Longer image verification and treatment delivery times of the MR-Linac also mean patient selection and intrafractional IGRT are likely to be integral to ensuring high quality clinical outcomes in this rare cancer.
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Affiliation(s)
- Drew Smith
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Australia; Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia.
| | - Kellie Knight
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia
| | - Jenny Sim
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia
| | - Daryl Lim Joon
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Australia
| | - Farshad Foroudi
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Australia; Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia
| | - Vincent Khoo
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Australia; Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
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